CONGESTIVE CARDIAC

FAILURE
By Jones H.M - MBA
 GENERAL OBJECTIVE
• At the end of the lecture/
discussion students should be
able to acquire knowledge on
congestive cardiac failure and its
management.
 SPECIFIC OBJECTIVES
At the end of the lecture/discussion
students should be able to:
1. Describe the anatomy of the heart.
2. Define congestive cardiac failure.
3. State the causes of congestive
cardiac failure.
4. Outline the forms of congestive
cardiac failure.
 CONT…
8. Explain compensatory
mechanisms of congestive
cardiac failure.
6. Describe the pathophysiology of
congestive cardiac failure.
7. State the signs and symptoms of
congestive cardiac failure.
 CONT…
8. Describe the management of
congestive cardiac failure.
9. State the complications of
congestive cardiac failure.
10. Explain the health education
given on discharge.
 INTRODUCTION
• Heart failure is as a result of undue
stress upon the heart.
• It represents failure of the heart
muscle to pump sufficient blood to
meet the body’s metabolic need.
• The acute heart failure develops
swiftly when the heart muscle
suddenly fails in its function as a
pump.
 CONT…
• The results of sudden heart
failure are shock, cardiac arrest,
syncope and sudden death.
• On the other hand heart failure
which develops slowly is known
as chronic congestive cardiac
failure.
ANATOMY OF THE HEART
 DEFINITION
• Congestive cardiac failure is the
inability of the heart to pump
sufficient blood to meet the
needs of the tissues for oxygen
and nutrients.(smeltzer etal, 2010)
.
CAUSES OF CONGESTIVE CARDIAC
FAILURE
•Reduced blood volume due dehydration
and haemorrhage, this results in a
reduction in the flow of blood to the heart
thereby reducing its cardiac output.
•Increased blood volume-this can be due
to excessive intravenous fluids, sodium
and water retention; this increases the
workload of the heart.
 CONT…
• Valvular heart disease for example
Rheumatic heart disease- this
results in valvular stenosis or
regurgitation.
• Damage to the heart muscle from
either ischaemia(myocardial
infarction) or inflammation
process(myocardiatis).
 CONT…
• Conditions like anaemia, fever,
hyperthyroidism or pregnancy that
increases the metabolic needs of the
body also increases the workload of
the heart.
• Arteriosclerotic disease-it’s a
condition characterized by hardening
and loss of elasticity of walls.
 CONT…
• Hypertensive cardiovascular disease-
hypertension if sustained for a long
period of time causes irreversible
degenerative changes within the
arterial walls.
• Constrictive pericarditis- as a result
of infection the pericardium may
become inflamed, scarred and
constricted.
 CONT…
• Pulmonary disease for example
chronic tuberculosis causes
damage to the arteries of the
lungs.
FORMS OF CONGESTIVE CARDIAC
FAILURE
• Right sided failure.
• Left sided failure.
COMPENSATORY MECHANISM
• As heart failure develops, the
body activates neurohormonal
compensatory mechanisms.
• These mechanisms represent the
body’s attempt to cope with the
failing heart.
 CONT…
1. Due to the reduced cardiac output
the sympathetic system is
stimulated which leads to
production of adrenaline which
brings about the fight and flight
reaction.
• There is tachycardia and
palpitations.
 CONT…
2. A decrease in blood supply to the
kidneys leads to production of renin
which convents angiotensinogen to
angiotensin I.
• Angiotensin I is converted to
angiotensin II by angiotensin
coverting enzyme.
• Angiotensin II is a powerful
vasoconstrictor.
 CONT…
• Angiotensin II also stimulates the
adrenal gland to release
aldosterone resulting in sodium
and fluid retention by renal
tubules and stimulating the
antidiuretic hormone leading to
increased blood volume.
 CONT…
3. Ventricular dilatation.
• As the heart’s workload increases,
the contractility of the myocardial
muscle fibers decreases.
 CONT…
• Decreased contractility results in
an increase in end-diastolic blood
volume in the ventricle, stretching
the myocardial muscle fibers and
increasing the size of the
ventricle.
 CONT…
4. Ventricular hypertrophy
• Due to the increased workload of
the heart there is abnormal
proliferation of the myocardial
cells this increases the
contractility of the heart though it’s
also for a short while, as the heart
eventually fails.
 PATHOPHYSIOLOGY
• One of the causes of heart failure is
ischaemic heart disease for example
myocardial infarction.
• When the myocardium of the left
ventricle is diseased the left ventricle
will fail to eject blood fully into the
aorta to the general circulation.
 CONT…
• When this happens there will be a
residue of blood in the left ventricle
with each ejection.
• The residue in turn will decrease
the ventricles capacity to receive
blood from left atrium.
• This means the left atrium should
work hard to eject its blood, as a
result it hypertrophies and dilates.
 CONT…
• If the left atrium cannot fully eject
its blood in the left ventricle, the
result is that it will be unable to
receive the full amount of
incoming blood from the
pulmonary veins.
 CONT…
• Once this happens, it leads to
congestion of the pulmonary
system and to symptoms that are
respiratory in nature such as
dyspnoea, Orthopnoea,
paroxysmal nocturnal dyspnoea,
cough, pleural effusion and
pulmonary oedema.
 CONT…
• The increased pressure in the
pulmonary vascular system entails that
the right ventricle should work extra
hard to pump blood into the pulmonary
system against the increased pressure.
• When this happens the right ventricle
dilates and hypertrophies in order to
meet its increased workload.
 CONT…
• It eventually fails, this causes
engorgement of the venous system
which extends backwards to produce
congestion in the gastro intestinal tract,
abdominal viscera and the kidneys.
• This manifests as oedema, ascites,
gastro intestinal tract symptoms such
as nausea and anorexia.
 SIGNS AND SYMPTOMS
Left sided failure
• Dyspnoea or shortness of
breathe- It results from
congestion of the patient’s lungs
owing to pulmonary engorgement.
• Orthopnoea- inability to breath
well while in recumbecy.
 CONT…
• Paroxysmal nocturnal dyspnoea-
This is dyspnoea which awakes the
patient from sleep and forces him/
her to get out of bed to catch their
breathe. The reason is that in the
lying position there is an increase in
the venous return to the lungs
causing severe congestion.
 CONT…
• Pleural Effusion and Pulmonary
Oedema- these are as a result of
pulmonary congestion which is
so severe that the distended
capillaries leak fluid into the
interstitial and alveolar spaces of
the lungs.
 CONT…
• Cough and cardiac asthma- the
cough is productive with large
frothy blood tinged sputum. The
cough is due to irritation of the
lung tissue by the large amount of
fluids trapped in the pulmonary
tree.
 CONT…
• Decreased renal function,
oedema and weight gain.
• Cerebral anoxia.
• Fatigue and muscular weakness
 CONT…
Right Sided Failure
• Liver enlargement and abdominal
pains as the liver becomes congested
with venous blood, it enlarges.
• This stretches the capsule surrounding
the liver causing discomfort and the
patient may complain of consistent
aching in the right upper quadrant or
sharp pain.
 CONT…
• Anorexia and nausea- these
develop secondary to venous
congestion in the gastro intestinal
tract which delay digestion.
 CONT…
• Dependent oedema.
• Coolness of the extremities.
• Abdominal ascites.
• Distended jugular veins.
 INVESTIGATION

•Health history may reveal the

following information;
Activity intolerance.
Nocturnal paroxysmal dyspnoea.
Tachycardia.
Orthopnoea.
Family history.
 CONT…
• Physical Assessment.
On inspection patient may appear
breathless at rest or after an
activity.
Auscultation of the respiratory
tract will disclose crackles due to
pulmonary oedema.
 CONT…
Assessment of cardiovascular
system may reveal abnormal
heart sounds.
On palpation, oedema is seen in
dependent areas such as sacrum
and ankles .
 CONT…
• Chest X-ray will show an
enlarged heart, pulmonary and
venous congestion and interstitial
oedema.
• Electrocardiogram may show
evidence of a myocardial
infarction and arrhythmias.
 CONT…
• Echocardiography with Doppler
flow studies will show cardiac
structure integrity and function.
• Arterial blood gas analysis to
detect alkalosis or acidosis.
Early heart failure usually manifests
with alkalosis due to
hyperventilation
 CONT…
Late heart failure manifests with
acidosis due to reduced oxygen
perfusion.
• Laboratory tests;
Blood Urea Nitrogen and Creatinine
for kidney function will be raised.
Liver Function Test will reveal
elevated liver enzymes.
 CONT…
Full Blood Count might show low
haemoglobin and red blood cell
count.
 MEDICAL TREATMENT
• Digoxin(cardiac glycoside) 1-1.5mg
digitalizing dose stat and 0.2mg po
daily. It can however be
administered intravenous or
intramuscular only when the patient
life is threatened otherwise digoxin
is almost always administered orally.
IV/IM digitalizing dose is 0.5-1mg.
 CONT…
• Action: It increases the
myocardial contractility.
• Nursing Implication: Take apical
beat and withhold the medication
if less than 60 beats per minute.
• Side effects: Brandycardia and
hypotension.
 CONT…
• Diuretics: For example frusemide
10-20mg IV stat then 20mg PO
once daily.
• Action: It promotes excretion of
sodium, water and chloride by
inhibiting their tubular re-
absorption.
 CONT…
• Side effects: Dehydration, Polyuria,
electrolyte imbalance and
hypovolaemia.
• Nursing Implication: Observe for
electrolyte abnormalities and
decreased blood pressure.
• Careful monitor intake and output
and daily weighing.
 CONT…
• Slow K: it’s a potassium sparing
diuretic, give 600mg OD PO to
replace the potassium lost
through diuresis.
 CONT…
• Captopril (Capoten): 12.5mg tds.
• Action: Angiotensin Converting
Enzyme inhibitor which reduces
blood pressure and afterload.
• Side Effects : Tachycardia,
anorexia and hypersensitivity
rashes.
 CONT…
• Nursing Implication: Do not
administer drug in patients with
known hypersensitivity.
• Use cautiously in patients with
impaired renal function.
 CONT…
• Atenolol- 50 mg orally once daily.
• Action: Beta-adrenergic
antagonists (beta blockers) which
reduces BP by antagonizing beta
adrenergic effects thus
counteracting vasoconstriction
and reducing renin secretion by
the kidneys.
 CONT…
• Side Effects: Tachycardia,
headache and palpitations.
• Nursing Implications: Observe for
decreased heart rate,
symptomatic hypotension and
fatigue.
 NURSING CARE
AIMS
• To reduce myocardial workload
• To improve ventricular pump
performance.
• To promote lifestyle conducive to
cardiac health.
 ENVIRONMENT
• The patient will be nursed in an
acute bay on a cardiac bed for
easy observation by the nursing
staff.
• Maintain a calm environment to
decrease anxiety which increases
the workload of the heart.
 CONT…
• Maintain a warm environment to
promote blood vessel dilatation
and tissue perfusion.
• There should be a cardiac table
for the patient to lean on and
oxygen source as patient can be
dyspnoeic.
 POSITION
• Nurse the patient in a fowler’s
position to relieve pulmonary
congestion and dyspnoea.
• Maintain the legs in the
dependent position as much as
possible as elevating the legs can
rapidly increases venous return.
 REST
• Put the patient on complete bed rest
to reduce the workload of the heart
and reduce tissue demand for oxygen.
• Space nursing activities to prevent
fatigue which increases the
myocardial oxygen demand.
• Schedule rest periods in order to
conserve the patient’s energy
reserves
 CONT…
• Gradually increase activities to gain
cardiac conditioning and improve
activity tolerance.
• change the patients position
whenever necessary to make him
comfortable and allow for rest.
• Administer oxygen by naso catheter
or mask to relieve dyspnoea thereby
allowing rest.
 PSYCHOLOGICAL CARE

• Reassure the patient that the

dyspnoea will be relieved by the
position, administration of oxygen
and diuretics to reduce the
pulmonary congestion.
• Explain to the patient that he is on
total bed rest to allow the heart to
rest and that he will resume activities
once condition improves.
 CONT…
• Explain the reason for fluid and
sodium restriction that is to reduce
body fluid retention which puts
strain on the already diseased
heart.
• Allow patient to be visited by
significant others to maintain
family ties and also for the patient
to feel cared for.
 CONT…
• Provide diversional therapy by
talking to the patient or offering
him a magazine for him to read to
keep the patients mind off the
condition.
 OBSERVATION

• Maintain strict intake and output to

avoid overloading the patient which
can put further strain on the heart.
• Weigh the patient daily on the same
scale wearing same clothes. Weight
is a guide to diuretic treatment and
the degree of oedema.
 CONT…
• Check for dependent oedema on
the sacrum and lower limbs.
• Check pulse 4 hourly to rule out
bradycardia a sign of cardiac shock.
• Check respirations 4 hourly to rule
out dyspnoea secondary to
pulmonary congestion.
 CONT…
• Check temperature 4 hourly , if high
it could be due to secondary
infection as temperature is usually
low or even subnormal in heart
failure.
• Blood pressure to rule out cardiac
shock.
• Observe the pressure points for
pressure sores.
 CONT…
• Observe for signs of dehydration
by checking the skin tugor and
eyes suckenness as dehydration
is a side effect of diuretic therapy.
• Observe the patient for ascites by
taking an abdominal
circumference daily.
 NUTRITION

• Reduce salt intake in the diet to

reduce sodium retention.
• Offer small frequent easily digestible
meals as heavy meals put strain on
the heart, small meals also helps to
avoid overloading the already
congested gastro intestinal tract.
 CONT…
• Reduce or restrict fluid intake to
reduce fluid retention
• Provide oral toilet to the patient to
stimulate appetite especially if
patient is on oxygen.
 HYGIENE

• In acute phase provide bed baths

for the patients comfort while
ensuring that the patient is having
adequate rest.
• Oral toilet to moisten the oral
mucosa and prevent halitosis
especially if patient is on oxygen
and on fluid restriction.
 CONT…
• Change the patients bed linen
whenever wet as moisture can bring
about skin break down.
• Ensure that the bedding are
straightened and that there are no
craps as these predisposes to skin
break down or pressure sore
formation.
 CONT…
• Carry out pressure area care to
prevent skin break down as the
patient is almost always
oedematus.
 ELIMINATION
• Offer the patient a commode or
bed pan for bowel movement to
prevent constipation.
• Ensure strict intake and output to
monitor urinary function.
 CONT…
• Give a diet rich in roughage for
example cabbage, to increase the
bulky of stool thereby easing
bowel movement.
 EXERCISES

• While patient is in the acute phase

they should not do any exercises but
be allowed strict bed rest.
• As patient becomes less dyspnoeic
carry out passive exercises to prevent
the complications of prolonged bed
rest such as Deep Vein Thrombosis
and pressure sore formation.
 CONT…
• Once the patient is no longer
dyspnoeic and can tolerate some
activities he/she should be
allowed to sit out of bed then
walk to the toilet as necessary.
 COMPLICATIONS
• Acute pulmonary oedema:
characterized by severe dyspnoea,
Orthopnoea, pallor, tachycardia and
expectoration of large amounts of
frothy blood stinged sputum.
• Deep Vein Thrombosis:due to
prolonged bed rest
 CONT…
• Pressure Sore Formation: Due to
prolonged bed rest.
• Renal Failure: Due to inadequate
kidney perfusion.
• Portal Hypertension: Due to
congestion in the hepatic veins and
this results in oesophageal varices
and haemorrhoids.
 HEALTH EDUCATION
Medication
• Advise the patient to take the
medication as per doctor’s
prescription to improve cardiac
function.
Activity
• Inform the patient to avoid
strenuous physical activity
 CONT…
Follow up Care
• Advise the patient to regularly
attend the cardiac clinic.
• Monitoring of Disease Progress.
• Patient should be vigilant and
seek medical care immediately
for symptoms such as;
 CONT…
• sudden chest pain radiating to the
arm, severe breathlessness and
racing heart beat.
 CONT…
Diet Restrictions
• Inform the patient to adhere to a
low sodium diet in order to
reduce fluid retention.
• The patient should also consume
potassium rich food to prevent
hypokaleamia.
 SUMMARY
• Congestive Cardiac failure is the
inability of the heart to pump
sufficient blood to meet the needs
of the tissues for oxygen and
nutrients.
• Among the causes is myocardial
infarction, arteriosclerotic diseases
and rheumatic heart disease.
 CONT…
• There are two forms of congestive
cardiac failure left sided and right
sided failure.
• The cardinal signs and symptoms
of left sided failure is dyspnoea,
Orthopnoea, paroxysmal nocturnal
dyspnoea, cough, pleural effusion
and pulmonary oedema.
 CONT…
• The signs and symptoms of right
sided failure are oedema, ascites,
nausea and anorexia.
 REFERENCES
• Dirksen, H. L., (2004). Medical Surgical
Nursing.6 ed. Elsevier Mosby: Mousori.
th

• Long, B., (1993). Medical Surgical Nursing, A

Nursing Care Approach.3 ed. Mosby: Mousori.
rd

• Smeltzer et al, (2010).Brunner and Suddarth’s

Textbook of Medical- Surgical Nursing.20 th

edition, London: Lippincott William and Wilkins.

• Kumar. P., and Clark.M. eds., (2005). Clinical
medicine 6 ed. St Louis: Elsevier Saunders.
th
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